CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
6-year-old with Ear Pain 2
A 6-year-old female presented to the emergency department (ED) with complaint of ear pain for the past week. Her father reported the child has had congestion for a week but denied fever. She had no other complaints—although her father questioned if her hearing could be tested since “she hasn’t seemed to hear well for a few months.” In the ED, the patient was afebrile and had clear rhinorrhea. Her Wispr digital otoscope exam is shown.
Which of the following best describes the child’s tympanic membrane (TM)?
A. Normal
B. Dull and mildly bulging
C. Mildly retracted
D. Intensely erythematous and severely bulging
Answer: C. Mildly retracted
This child’s tympanic membrane (TM, “eardrum”) is mildly retracted as evidenced by the very prominent lateral process of the malleus. This occurs as negative pressure within the middle ear pulls the TM inward, particularly in the pars flaccida portion of the membrane. The resultant accentuation of the malleolar folds creates a “tent-like” appearance to the membrane (with the lateral process acting as the central tent pole). TM retraction is commonly observed in children with otitis media with effusion (OME) or with Eustachian tube dysfunction. While most resolve spontaneously, complications of persistent or severe retraction include hearing deficits as well as formation of deeper localized retraction pocket or cholesteatoma. Further evaluation with tympanometry (negative “C curve” tympanogram) and hearing assessment as well as ENT referral may be indicated if the child remains symptomatic.
Dull and mild bulging along with erythema and severe bulging would be consistent with acute otitis media (AOM), which is not present here. Here is an example of a normal tympanic membrane without pars flaccida retraction.
